Evaluating the Impact of Harm Reduction Vending Machines on Supply Distribution: A 23-Month Pre/Post Evaluation

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Although syringe services programs reduce harms, reliance on face-to-face encounters and limited operating hours constrain access. Harm reduction vending machines (HRVMs) dispense sterile syringes, condoms, fentanyl test strips, and related supplies through private, low-barrier pathways that may overcome these barriers. Yet, evidence from integrated health systems, including the Veterans Health Administration (VHA), remains limited. We evaluated whether HRVM implementation was associated with changes in harm reduction supply distribution across VHA clinical and housing settings. Methods This retrospective quality improvement evaluation was completed July 2025. Primary outcome was change in total syringes dispensed (pre-HRVM implementation: 8/31/21 − 7/31/23; post-HRVM implementation: 8/1/23 − 7/1/25). Secondary outcomes evaluated change in condoms, fentanyl test strips (FTS), and sharps containers dispensed. Data were collected from HRVM software and clinical logs. Pre/post totals were compared with Chi-square goodness-of-fit tests (α = 0.001). Results All supply categories increased significantly post-HRVM implementation (p < 0.001). Syringe distribution increased 9.5-fold (3,420 to 32,390; +847%), condoms 16.9-fold (854 to 14,475; +1,595%), sharps containers 9-fold (74 to 664; +797%), and FTS 3.6-fold (1,857 to 6,701; +261%). HRVMs accounted for 59–101% of these increases. Conclusions HRVM installation was associated with substantial, sustained growth in supply distribution, suggesting HRVMs can expand low-barrier access and complement clinic-based services for Veterans facing logistical or stigma-related barriers. Rigorous time-series or regression studies linking distribution to clinical outcomes are warranted. Collectively, these findings support system-wide VA scale-up of HRVMs as a low-barrier complement to clinic-based services. Harm reduction Veterans Vending machines Overdose prevention Syringe distribution Fentanyl test strips Public health Condoms Syringe disposal Figures Figure 1 Background Drug overdose and drug-related infections remain major public health challenges in the United States (US), with disproportionate impacts among people experiencing homelessness, who use drugs, and with co-occurring mental health conditions. 1 – 3 Veterans encompass many of these intersecting risks and also face unique barriers to preventive services, including stigma, lack of transportation, confidentiality concerns, and healthcare ineligibility. 4 – 8 Within the Veterans Health Administration (VHA), expanding low-barrier access to harm reduction supplies is therefore a health equity priority. Harm reduction approaches, including syringe service programs (SSPs), safer-use education, naloxone, syringes, sharps containers, condoms, and fentanyl test strips (FTS), reduce individual and community harms without requiring abstinence. 9 – 12 Yet, even where these services exist, reach can be limited by geography, staffing, hours of operation, and perceived judgment in clinical environments. 13 – 15 These access limitations can suppress uptake among those who might benefit most. Harm reduction vending machines (HRVMs) have emerged as a complementary strategy to extend reach. Typically placed in community-based settings (e.g. shopping areas, community centers, pharmacies, libraries, universities, commercial sex venues), HRVMs provide no- or low-barrier access to vital harm reduction supplies. 16 – 20 HRVMs are accessible, acceptable, convenient, and promote anonymity and privacy, drawing in people who may not use traditional SSP or clinic-based services. 21 – 25 However, evidence from integrated health systems, including VHA, remains limited. Moreover, few studies examine how HRVMs function alongside existing clinical channels, leaving open questions about whether increases reflect new access versus substitution from other sources. VHA has articulated a system-level commitment to overdose prevention, 26,27 prevention and treatment of human immunodeficiency virus (HIV) 28 , 29 and hepatitis C virus (HCV), 30–32 and harm reduction. Yet, implementation barriers such as lack of procurement protocols, low supply chain reliability, data collection requirements, and lack of local health system support can impede scale-up. 33–36 Further, harm reduction programs within VHA are fairly new with limited staffing and funding capacity. 34 , 35 Generating pragmatic evidence on whether HRVMs expand overall access to harm reduction resources within VHA, and how they contribute relative to other distribution channels, can inform policy and operational decision-making. To address these gaps, we conducted a 23-month pre/post evaluation of HRVM implementation across VHA clinical and supportive housing settings. We quantified changes in distribution of harm reduction supplies (syringes, sharps containers, condoms, fentanyl test strips) and estimated HRVMs’ share of total distribution relative to other methods. Our objective was to assess whether HRVMs are associated with meaningful, sustained increases in access to critical supplies and to inform equity-focused scale-up within VHA and similar systems. Methods Design and Setting This was a retrospective, observational quality improvement (QI) project completed at the San Francisco Veterans Affairs Health Care System (SFVAHCS), which serves over 310,000 US Veterans at the San Francisco VA Medical Center and 9 community-based outpatient clinics (CBOCs) located in Downtown San Francisco, Oakland, San Bruno, Santa Rosa, Clearlake, Ukiah, and Eureka, California. The project was led by the SFVAHCS Harm Reduction Program, whose mission aims to end drug-related stigma and discrimination in health care, prevent the spread of drug-related infections and overdose deaths, and increase Veteran connections to services. The program provides harm reduction education, supplies, and clinical services to Veterans via in person-, telephone-, and referral-based care. Starting August 2023, fifteen harm reduction vending machines (HRVMs) were installed as part of a broader institutional harm reduction expansion strategy. Two are located at the San Francisco VA Medical Center, seven in CBOCs (all cities except San Bruno), and six in San Francisco Bay Area supportive housing buildings where Veterans live. All HRVMs were designed with the same interior layout and products, which dispense free of charge and anonymously. Interested Veterans (any healthcare eligibility) complete a one-time sign-up for access to HRVMs in-person or via telephone call with the SFVAHCS Harm Reduction Program pharmacist, pharmacy trainee, or point of contact collocated with the HRVMs. Harm Reduction Supply Distribution Pathways As shown in Fig. 1 , Veterans are provided syringes, sharps containers, condoms, and fentanyl test strips through a variety of pathways. This low-barrier, multi-modal approach allows flexibility for Veterans who may be unable to access services in person (geography, transportation, cost), prefer anonymity versus a prescription, or are ineligible/unable to access healthcare benefits within the VA. In addition, a variety of sizes/materials are available to support each Veteran’s unique needs (e.g., non-latex condoms for Veterans/their partners with an allergy). Outcomes The primary outcome evaluated was change in total number of syringes distributed in the 23 months pre- (8/31/21 to 7/31/23) and post-HRVM implementation (8/1/23 to 7/1/25). Secondary outcomes included changes in the total number of condoms, fentanyl test strips, and sharps containers distributed. Data Collection Distribution data for syringes, sharps containers, condoms, and fentanyl test strips were obtained from clinic distribution logs and HRVM web-based software (EMS from VendNovation, LLC). Distribution data for condoms and fentanyl test strips obtained from state-based sources (California Department of Public Health Office of AIDS Condom Distribution Program; California Department of Health Care Services Naloxone Distribution Project) were excluded, as these resources were only available during the post-HRVM implementation period, precluding pre/post comparisons. Data Analysis Descriptive statistics were used to summarize harm reduction supply distribution across pre- and post-HRVM implementation periods. Pre/post comparisons were performed using chi-square goodness-of-fit tests at α = 0.001, 0.01, and 0.05 significance levels (Claude, 2025). This approach is appropriate for evaluating differences in count data between two independent time periods without assuming a specific distribution. 37 , 38 Results As shown in Table 1 , distribution counts of all four categories of harm reduction supplies (syringes, condoms, fentanyl test strips, sharps containers) increased from the 23 months pre- to post-HRVM implementation period. Table 1 Total Number of Harm Reduction Supplies Distributed 23 Months Pre- and Post-Implementation of HRVMs. Harm Reduction Supplies Distributed 23 Months Pre-HRVM (8/31/21–7/31/23) 23 Months Post-HRVM (8/1/23–7/1/25) Total syringes distributed 3420 32390 Via prescription 2460 4840 Via VA safer injection kits 960 920 Via HRVM 0 26630 Total condoms distributed 854 14475 Via prescription 406 600 Via VA safer sex kits 448 55 Via HRVM 0 13820 Total fentanyl test strips distributed 1857 6701 Via outpatient/inpatient pharmacy 1857 3841 Via HRVM 0 2860 Total sharps containers distributed 74 664 Via prescription 25 54 Via VA safer injection kits 49 50 Via HRVM 0 560 Abbreviations: HRVM, harm reduction vending machine; VA, Veterans Affairs. As shown in Table 2 , all four supply types demonstrated highly statistically significant increases in distribution (p < 0.001). Chi-square statistics ranged from 4,704 to 245,398 across supply categories, far exceeding critical values. The largest effect size was for condoms, which increased from 854 to 14,475 dispensed (1,595% increase; 16.9-fold change). HRVMs accounted for most distribution increases, ranging from 59–101%. Table 2 Statistical Analyses of Harm Reduction Supply Distribution 23 Months Pre- and Post-Implementation of HRVMs. Harm Reduction Supply Category Absolute Increase Percent Increase Fold Change Percent Increase Attributable to HRVMs Chi-Square Syringes 28,970 847% 9.5x 92% 245,398 Condoms 13,621 1,595% 16.9x 101% 217,250 Fentanyl test strips 4,844 261% 3.6x 59% 12,636 Sharps containers 590 797% 9.0x 95% 4,704 All four supply categories demonstrated statistically significant increases, p < 0.001. Discussion These findings align with prior research of HRVMs in non-VA settings, demonstrating that private, low-barrier access increases harm reduction supply distribution (syringes, naloxone, and other drug use supplies), particularly among individuals who may avoid in-person services due to stigma and structural barriers. 22 , 39 – 43 Within the SFVAHCS, where multiple harm reduction distribution channels already exist, the observed HRVM contribution indicates meaningful added capacity rather than simple substitution of service delivery. The > 100% HRVM share for condom distribution increases suggests some substitution, which aligns with practice, as free VA safer sex kits were a time-limited service. For other supplies (syringes, sharps containers, fentanyl test strips), HRVMs expanded overall access. Because our design is pre/post intervention, these patterns should be interpreted as changes in distribution methods and volume, rather than causal effects; yet, the magnitude and consistency across categories point to real operational value. Future research could incorporate interrupted time-series or count-regression models to strengthen influence. Public Health Implications Veterans experiencing homelessness, transportation barriers, shift work, healthcare ineligibility, or concerns about stigma may be especially sensitive to access barriers. 8 , 44 , 45 The SFVAHCS HRVMs effectively address several barriers simultaneously, including privacy, anonymity, no cost, strategic placement, and 24/7 availability. This is consistent with VHA’s health equity commitment and national goals to reduce drug overdose deaths and transmission of HIV and HCV. 27 , 28 , 31 Future work should directly measure equity-relevant outcomes (e.g., utilization among homeless Veterans and those with limited/no VA healthcare engagement). Expanded distribution of syringes, sharps containers, condoms, and fentanyl test strips represents a vital step towards reducing overdose and related infections. 46 – 51 In practice, HRVMs can stabilize supply access in between in-person clinic or SSP visits, offer discreet access for sensitive items, and extend reach into VA supportive housing. Programs should pair HRVMs with communication strategies that normalize use (e.g., signage emphasizing confidentiality and safety), robust syringe disposal resources (e.g. 38-gallon sharps disposal bins), and health service linkage, including STI testing, treatment, and prevention (e.g., HIV pre-exposure prophylaxis, doxycycline post-exposure prophylaxis), and substance use disorder treatment. Future research could evaluate use of quick response codes, smart apps, or text messaging services to facilitate directly linking Veterans to health services. Future Directions For VHA health system leaders, four operational factors merit early attention: securing long-term funding, providing adequate program staffing (purchasing inventory maintenance, product packaging, stocking, program evaluation and changes), mitigating supply chain issues (obtaining new contracts, mitigating stockouts), and maintaining data systems that allow some tracking/program evaluation while also preserving participant anonymity. Beyond initial start-up costs, sites should budget for annual fees (e.g., software, wi-fi, maintenance), increases in product demand, and new parts (e.g., coils). In addition, feedback from program participants is vital to ensure products are need-based and can be modified based on changing trends in the street drug supply, incorporate newly available harm reduction tools, and are equity-driven. When located in community-based settings, memoranda of understanding/agreement can clarify roles and responsibilities for maintenance, stocking, physical space, data sharing, and products stocked (e.g., if safer smoking supplies are allowed in non-smoking housing buildings). Overall, these results support integrating HRVMs as a standard, low-barrier component of VHA harm reduction services, paired with dependable resourcing, coordinated data systems, and equity-focused evaluations, to strengthen public health infrastructure and reduce preventable harms among Veterans. Limitations This evaluation was conducted at a single VA healthcare system serving a Veteran population in Northern California; therefore, generalizability to other settings and populations is limited. In the absence of a control group, estimates may be influenced by temporal trends, seasonality, or co-occurring initiatives (e.g., outreach events, workflow changes, shifts in supply availability) that were not fully measured. Counts were aggregated across channels and reflect units dispensed rather than unique individuals; as such, they are vulnerable to inaccuracies (e.g., data entry error, HRVM down time). State-supplied condom and fentanyl test strip distribution data were excluded because no pre-implementation comparators were available; consequently, post-implementation totals may understate overall access, and the proportion attributed to HRVMs may be over- or under-estimated. Observed HRVM contribution percentages reflect the percentage share of all items dispensed via HRVMs (HRVM count divided by total count) and should not be interpreted as causal effects; some increases may reflect substitution from non-HRVM channels (e.g., declines in safer sex kit distribution) rather than new distribution. Our chi-square comparisons of totals do not account for month-to-month autocorrelation; interrupted time-series or count regression models (e.g., Poisson/negative binomial) could provide stronger causal inference. Finally, we did not assess downstream outcomes (e.g., overdose, incidence of HIV, HCV, STIs), so clinical impact cannot be inferred from distribution alone. Conclusions Implementation of HRVMs in a VA healthcare system was associated with substantial and sustained increases in harm reduction supply distribution, including condoms (+ 1,595%), syringes (+ 847%), sharps containers (+ 797%), and fentanyl test strips (+ 261%). Of all distribution methods utilized, HRVMs accounted for the most increases. While findings cannot establish causality, they indicate that HRVMs can rapidly expand low-barrier access and complement existing SSPs services, particularly for populations experiencing stigma or logistical barriers to clinic-based services. Health systems and policymakers should consider integrating HRVMs into routine harm reduction workflows, ensure stable funding, supply chain reliability, and maintenance. Future evaluations using time-series or regression designs and examining diverse settings, populations, and downstream clinical outcomes (overdose, incidence of HIV, HCV, sexually transmitted infections) are warranted. Collectively, these findings support system-wide VA scale-up of HRVMs as a low-barrier complement to clinic-based harm reduction services. Abbreviations Harm reduction vending machines, HRVMs; Hepatitis C Virus, HCV; Human Immunodeficiency Virus, HIV; Institutional Review Board, IRB; San Francisco Veterans Affairs Health Care System, SFVAHCS; Sexually Transmitted Infection, STI; Syringe Services Programs, SSPs; United States, US; US Housing and Urban Development-Veterans Affairs Supporting Housing, HUD-VASH; Veterans Affairs, VA; Veterans Health Administration, VHA. Declarations Author Contribution CRediT Author Statement: Apana: writing (original draft, review, and editing), visualization. Xie: writing (review and editing). Douglas: methodology, formal analysis, data curation, writing (review and editing), visualization, funding acquisition. Rife-Pennington: conceptualization, methodology, software, validation, formal analysis, investigation, resources, data curation, writing (original draft, review, and editing), visualization, supervision, project administration, funding acquisition. 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Francisco","correspondingAuthor":false,"prefix":"","firstName":"Wendy","middleName":"","lastName":"Xie","suffix":""},{"id":571065154,"identity":"7fbe2cc4-bc16-4302-9aab-ed38b8837cea","order_by":2,"name":"Michael Douglas","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Douglas","suffix":""},{"id":571065157,"identity":"af6ed6dd-da84-4c57-befb-6b775ef881d2","order_by":3,"name":"Tessa Rife-Pennington","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBADHvYG5gNEKoXRPAfYEkjTwsBzgMeAOC327O2PP/xguCfDw97zTeIHQ62cASH38fCcMZPsYSjm4eE5uw3IOG5MWItEDhvQdQk89hK5mw14GI4lzmwgpEX++eOPf4BaeOTfPDb8Q5QWCQYDaZAtPBI8jI95GGoS+wnoYOA5k2MmLWMA1MKTZvhYxuCAMT8hLeztxx9/fFORYM/DfvjBwTcVdXJshLRAADxGDA4TpwEZ1JGuZRSMglEwCoY9AACNyjV/UGT/JwAAAABJRU5ErkJggg==","orcid":"","institution":"San Francisco VA 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12:25:00","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":105035,"visible":true,"origin":"","legend":"","description":"","filename":"17dd5942274d4c6e8052e6f45eef94971structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7787003/v1/e3623d68164796c7143d8f4d.xml"},{"id":99885682,"identity":"1d65728b-6c44-46a9-b7b0-f091090495e8","added_by":"auto","created_at":"2026-01-09 12:25:00","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":117274,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7787003/v1/41cb92563d5a725cd63ddf98.html"},{"id":99885675,"identity":"9f8beb47-f0ab-4e11-8029-e0a885a18937","added_by":"auto","created_at":"2026-01-09 12:24:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":289995,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution Methods, Delivery Pathways, and Features of Harm Reduction Supplies Distributed 23 Months Pre- and Post-Implementation of HRVMs.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e*Healthcare eligible Veterans only. Abbreviations: HRVMs, harm reduction vending machines; VA, Veterans Affairs; SFVAMC, San Francisco VA Medical Center\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7787003/v1/932767cc597a5175b0e567c9.png"},{"id":104779854,"identity":"50c55d63-b072-4436-8847-06dcd213addc","added_by":"auto","created_at":"2026-03-17 07:46:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":929874,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7787003/v1/a60dd396-8d82-4228-a6f4-775f4095a4c2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluating the Impact of Harm Reduction Vending Machines on Supply Distribution: A 23-Month Pre/Post Evaluation","fulltext":[{"header":"Background","content":"\u003cp\u003eDrug overdose and drug-related infections remain major public health challenges in the United States (US), with disproportionate impacts among people experiencing homelessness, who use drugs, and with co-occurring mental health conditions.\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Veterans encompass many of these intersecting risks and also face unique barriers to preventive services, including stigma, lack of transportation, confidentiality concerns, and healthcare ineligibility.\u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Within the Veterans Health Administration (VHA), expanding low-barrier access to harm reduction supplies is therefore a health equity priority.\u003c/p\u003e \u003cp\u003eHarm reduction approaches, including syringe service programs (SSPs), safer-use education, naloxone, syringes, sharps containers, condoms, and fentanyl test strips (FTS), reduce individual and community harms without requiring abstinence.\u003csup\u003e\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Yet, even where these services exist, reach can be limited by geography, staffing, hours of operation, and perceived judgment in clinical environments.\u003csup\u003e\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e These access limitations can suppress uptake among those who might benefit most.\u003c/p\u003e \u003cp\u003eHarm reduction vending machines (HRVMs) have emerged as a complementary strategy to extend reach. Typically placed in community-based settings (e.g. shopping areas, community centers, pharmacies, libraries, universities, commercial sex venues), HRVMs provide no- or low-barrier access to vital harm reduction supplies.\u003csup\u003e\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e HRVMs are accessible, acceptable, convenient, and promote anonymity and privacy, drawing in people who may not use traditional SSP or clinic-based services.\u003csup\u003e\u003cspan additionalcitationids=\"CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e However, evidence from integrated health systems, including VHA, remains limited. Moreover, few studies examine how HRVMs function alongside existing clinical channels, leaving open questions about whether increases reflect new access versus substitution from other sources.\u003c/p\u003e \u003cp\u003eVHA has articulated a system-level commitment to overdose prevention,\u003csup\u003e26,27\u003c/sup\u003e prevention and treatment of human immunodeficiency virus (HIV)\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e and hepatitis C virus (HCV),\u003csup\u003e30\u0026ndash;32\u003c/sup\u003e and harm reduction. Yet, implementation barriers such as lack of procurement protocols, low supply chain reliability, data collection requirements, and lack of local health system support can impede scale-up.\u003csup\u003e33\u0026ndash;36\u003c/sup\u003e Further, harm reduction programs within VHA are fairly new with limited staffing and funding capacity.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e Generating pragmatic evidence on whether HRVMs expand overall access to harm reduction resources within VHA, and how they contribute relative to other distribution channels, can inform policy and operational decision-making.\u003c/p\u003e \u003cp\u003eTo address these gaps, we conducted a 23-month pre/post evaluation of HRVM implementation across VHA clinical and supportive housing settings. We quantified changes in distribution of harm reduction supplies (syringes, sharps containers, condoms, fentanyl test strips) and estimated HRVMs\u0026rsquo; share of total distribution relative to other methods. Our objective was to assess whether HRVMs are associated with meaningful, sustained increases in access to critical supplies and to inform equity-focused scale-up within VHA and similar systems.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and Setting\u003c/h2\u003e \u003cp\u003e This was a retrospective, observational quality improvement (QI) project completed at the San Francisco Veterans Affairs Health Care System (SFVAHCS), which serves over 310,000 US Veterans at the San Francisco VA Medical Center and 9 community-based outpatient clinics (CBOCs) located in Downtown San Francisco, Oakland, San Bruno, Santa Rosa, Clearlake, Ukiah, and Eureka, California. The project was led by the SFVAHCS Harm Reduction Program, whose mission aims to end drug-related stigma and discrimination in health care, prevent the spread of drug-related infections and overdose deaths, and increase Veteran connections to services. The program provides harm reduction education, supplies, and clinical services to Veterans via in person-, telephone-, and referral-based care.\u003c/p\u003e \u003cp\u003eStarting August 2023, fifteen harm reduction vending machines (HRVMs) were installed as part of a broader institutional harm reduction expansion strategy. Two are located at the San Francisco VA Medical Center, seven in CBOCs (all cities except San Bruno), and six in San Francisco Bay Area supportive housing buildings where Veterans live. All HRVMs were designed with the same interior layout and products, which dispense free of charge and anonymously. Interested Veterans (any healthcare eligibility) complete a one-time sign-up for access to HRVMs in-person or via telephone call with the SFVAHCS Harm Reduction Program pharmacist, pharmacy trainee, or point of contact collocated with the HRVMs.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eHarm Reduction Supply Distribution Pathways\u003c/h3\u003e\n\u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Veterans are provided syringes, sharps containers, condoms, and fentanyl test strips through a variety of pathways. This low-barrier, multi-modal approach allows flexibility for Veterans who may be unable to access services in person (geography, transportation, cost), prefer anonymity versus a prescription, or are ineligible/unable to access healthcare benefits within the VA. In addition, a variety of sizes/materials are available to support each Veteran\u0026rsquo;s unique needs (e.g., non-latex condoms for Veterans/their partners with an allergy).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcome evaluated was change in total number of syringes distributed in the 23 months pre- (8/31/21 to 7/31/23) and post-HRVM implementation (8/1/23 to 7/1/25). Secondary outcomes included changes in the total number of condoms, fentanyl test strips, and sharps containers distributed.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eDistribution data for syringes, sharps containers, condoms, and fentanyl test strips were obtained from clinic distribution logs and HRVM web-based software (EMS from VendNovation, LLC). Distribution data for condoms and fentanyl test strips obtained from state-based sources (California Department of Public Health Office of AIDS Condom Distribution Program; California Department of Health Care Services Naloxone Distribution Project) were excluded, as these resources were only available during the post-HRVM implementation period, precluding pre/post comparisons.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarize harm reduction supply distribution across pre- and post-HRVM implementation periods. Pre/post comparisons were performed using chi-square goodness-of-fit tests at α\u0026thinsp;=\u0026thinsp;0.001, 0.01, and 0.05 significance levels (Claude, 2025). This approach is appropriate for evaluating differences in count data between two independent time periods without assuming a specific distribution.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, distribution counts of all four categories of harm reduction supplies (syringes, condoms, fentanyl test strips, sharps containers) increased from the 23 months pre- to post-HRVM implementation period.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTotal Number of Harm Reduction Supplies Distributed 23 Months Pre- and Post-Implementation of HRVMs.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarm Reduction Supplies Distributed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 Months Pre-HRVM\u003c/p\u003e \u003cp\u003e(8/31/21\u0026ndash;7/31/23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 Months Post-HRVM\u003c/p\u003e \u003cp\u003e(8/1/23\u0026ndash;7/1/25)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal syringes distributed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32390\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVia prescription\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e2460\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e4840\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVia VA safer injection kits\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e960\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e920\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVia HRVM\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e26630\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal condoms distributed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e854\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14475\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVia prescription\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e406\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e600\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVia VA safer sex kits\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e448\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e55\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVia HRVM\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e13820\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal fentanyl test strips distributed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1857\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6701\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVia outpatient/inpatient pharmacy\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e1857\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e3841\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVia HRVM\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e2860\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal sharps containers distributed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e664\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVia prescription\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e25\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e54\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVia VA safer injection kits\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e49\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e50\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVia HRVM\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e560\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAbbreviations: HRVM, harm reduction vending machine; VA, Veterans Affairs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, all four supply types demonstrated highly statistically significant increases in distribution (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Chi-square statistics ranged from 4,704 to 245,398 across supply categories, far exceeding critical values. The largest effect size was for condoms, which increased from 854 to 14,475 dispensed (1,595% increase; 16.9-fold change). HRVMs accounted for most distribution increases, ranging from 59\u0026ndash;101%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStatistical Analyses of Harm Reduction Supply Distribution 23 Months Pre- and Post-Implementation of HRVMs.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarm Reduction Supply Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsolute Increase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent Increase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFold Change\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePercent Increase Attributable to HRVMs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChi-Square\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSyringes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28,970\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e847%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.5x\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e245,398\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCondoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13,621\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,595%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.9x\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e101%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e217,250\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFentanyl test strips\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,844\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e261%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6x\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12,636\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSharps containers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e590\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e797%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.0x\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4,704\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eAll four supply categories demonstrated statistically significant increases, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThese findings align with prior research of HRVMs in non-VA settings, demonstrating that private, low-barrier access increases harm reduction supply distribution (syringes, naloxone, and other drug use supplies), particularly among individuals who may avoid in-person services due to stigma and structural barriers.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan additionalcitationids=\"CR40 CR41 CR42\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e Within the SFVAHCS, where multiple harm reduction distribution channels already exist, the observed HRVM contribution indicates meaningful added capacity rather than simple substitution of service delivery. The \u0026gt;\u0026thinsp;100% HRVM share for condom distribution increases suggests some substitution, which aligns with practice, as free VA safer sex kits were a time-limited service. For other supplies (syringes, sharps containers, fentanyl test strips), HRVMs expanded overall access. Because our design is pre/post intervention, these patterns should be interpreted as changes in distribution methods and volume, rather than causal effects; yet, the magnitude and consistency across categories point to real operational value. Future research could incorporate interrupted time-series or count-regression models to strengthen influence.\u003c/p\u003e\n\u003ch3\u003ePublic Health Implications\u003c/h3\u003e\n\u003cp\u003eVeterans experiencing homelessness, transportation barriers, shift work, healthcare ineligibility, or concerns about stigma may be especially sensitive to access barriers.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e,\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e The SFVAHCS HRVMs effectively address several barriers simultaneously, including privacy, anonymity, no cost, strategic placement, and 24/7 availability. This is consistent with VHA\u0026rsquo;s health equity commitment and national goals to reduce drug overdose deaths and transmission of HIV and HCV.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Future work should directly measure equity-relevant outcomes (e.g., utilization among homeless Veterans and those with limited/no VA healthcare engagement).\u003c/p\u003e \u003cp\u003eExpanded distribution of syringes, sharps containers, condoms, and fentanyl test strips represents a vital step towards reducing overdose and related infections.\u003csup\u003e\u003cspan additionalcitationids=\"CR47 CR48 CR49 CR50\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e In practice, HRVMs can stabilize supply access in between in-person clinic or SSP visits, offer discreet access for sensitive items, and extend reach into VA supportive housing. Programs should pair HRVMs with communication strategies that normalize use (e.g., signage emphasizing confidentiality and safety), robust syringe disposal resources (e.g. 38-gallon sharps disposal bins), and health service linkage, including STI testing, treatment, and prevention (e.g., HIV pre-exposure prophylaxis, doxycycline post-exposure prophylaxis), and substance use disorder treatment. Future research could evaluate use of quick response codes, smart apps, or text messaging services to facilitate directly linking Veterans to health services.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFuture Directions\u003c/h2\u003e \u003cp\u003eFor VHA health system leaders, four operational factors merit early attention: securing long-term funding, providing adequate program staffing (purchasing inventory maintenance, product packaging, stocking, program evaluation and changes), mitigating supply chain issues (obtaining new contracts, mitigating stockouts), and maintaining data systems that allow some tracking/program evaluation while also preserving participant anonymity. Beyond initial start-up costs, sites should budget for annual fees (e.g., software, wi-fi, maintenance), increases in product demand, and new parts (e.g., coils). In addition, feedback from program participants is vital to ensure products are need-based and can be modified based on changing trends in the street drug supply, incorporate newly available harm reduction tools, and are equity-driven. When located in community-based settings, memoranda of understanding/agreement can clarify roles and responsibilities for maintenance, stocking, physical space, data sharing, and products stocked (e.g., if safer smoking supplies are allowed in non-smoking housing buildings). Overall, these results support integrating HRVMs as a standard, low-barrier component of VHA harm reduction services, paired with dependable resourcing, coordinated data systems, and equity-focused evaluations, to strengthen public health infrastructure and reduce preventable harms among Veterans.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis evaluation was conducted at a single VA healthcare system serving a Veteran population in Northern California; therefore, generalizability to other settings and populations is limited. In the absence of a control group, estimates may be influenced by temporal trends, seasonality, or co-occurring initiatives (e.g., outreach events, workflow changes, shifts in supply availability) that were not fully measured. Counts were aggregated across channels and reflect units dispensed rather than unique individuals; as such, they are vulnerable to inaccuracies (e.g., data entry error, HRVM down time). State-supplied condom and fentanyl test strip distribution data were excluded because no pre-implementation comparators were available; consequently, post-implementation totals may understate overall access, and the proportion attributed to HRVMs may be over- or under-estimated. Observed HRVM contribution percentages reflect the percentage share of all items dispensed via HRVMs (HRVM count divided by total count) and should not be interpreted as causal effects; some increases may reflect substitution from non-HRVM channels (e.g., declines in safer sex kit distribution) rather than new distribution. Our chi-square comparisons of totals do not account for month-to-month autocorrelation; interrupted time-series or count regression models (e.g., Poisson/negative binomial) could provide stronger causal inference. Finally, we did not assess downstream outcomes (e.g., overdose, incidence of HIV, HCV, STIs), so clinical impact cannot be inferred from distribution alone.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eImplementation of HRVMs in a VA healthcare system was associated with substantial and sustained increases in harm reduction supply distribution, including condoms (+\u0026thinsp;1,595%), syringes (+\u0026thinsp;847%), sharps containers (+\u0026thinsp;797%), and fentanyl test strips (+\u0026thinsp;261%). Of all distribution methods utilized, HRVMs accounted for the most increases. While findings cannot establish causality, they indicate that HRVMs can rapidly expand low-barrier access and complement existing SSPs services, particularly for populations experiencing stigma or logistical barriers to clinic-based services. Health systems and policymakers should consider integrating HRVMs into routine harm reduction workflows, ensure stable funding, supply chain reliability, and maintenance. Future evaluations using time-series or regression designs and examining diverse settings, populations, and downstream clinical outcomes (overdose, incidence of HIV, HCV, sexually transmitted infections) are warranted. Collectively, these findings support system-wide VA scale-up of HRVMs as a low-barrier complement to clinic-based harm reduction services.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHarm reduction vending machines, HRVMs; Hepatitis C Virus, HCV; Human Immunodeficiency Virus, HIV; Institutional Review Board, IRB; San Francisco Veterans Affairs Health Care System, SFVAHCS; Sexually Transmitted Infection, STI; Syringe Services Programs, SSPs; United States, US; US Housing and Urban Development-Veterans Affairs Supporting Housing, HUD-VASH; Veterans Affairs, VA; Veterans Health Administration, VHA.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCRediT Author Statement: Apana: writing (original draft, review, and editing), visualization. Xie: writing (review and editing). Douglas: methodology, formal analysis, data curation, writing (review and editing), visualization, funding acquisition. Rife-Pennington: conceptualization, methodology, software, validation, formal analysis, investigation, resources, data curation, writing (original draft, review, and editing), visualization, supervision, project administration, funding acquisition.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis manuscript was reviewed using OpenAI\u0026rsquo;s ChatGPT (version GPT-5, August 2025) to assist with proofreading, clarity, grammar, and consistency. Claude (2025) was used to perform pre/post comparisons with chi-square goodness-of-fit tests. The use of generative AI complied with the ethical standards and institutional guidelines.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSpencer MR, Garnett MF, Mini\u0026ntilde;o AM. Drug Overdose Deaths in the United States, 2002\u0026ndash;2022. 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PLoS ONE. 2015;10(12):e0144869. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0144869\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0144869\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Harm reduction, Veterans, Vending machines, Overdose prevention, Syringe distribution, Fentanyl test strips, Public health, Condoms, Syringe disposal","lastPublishedDoi":"10.21203/rs.3.rs-7787003/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7787003/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDrug overdose and related infections remain major public health challenges within the United States, with disproportionate burden among Veterans. Although syringe services programs reduce harms, reliance on face-to-face encounters and limited operating hours constrain access. Harm reduction vending machines (HRVMs) dispense sterile syringes, condoms, fentanyl test strips, and related supplies through private, low-barrier pathways that may overcome these barriers. Yet, evidence from integrated health systems, including the Veterans Health Administration (VHA), remains limited. We evaluated whether HRVM implementation was associated with changes in harm reduction supply distribution across VHA clinical and housing settings.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective quality improvement evaluation was completed July 2025. Primary outcome was change in total syringes dispensed (pre-HRVM implementation: 8/31/21\u0026thinsp;\u0026minus;\u0026thinsp;7/31/23; post-HRVM implementation: 8/1/23\u0026thinsp;\u0026minus;\u0026thinsp;7/1/25). Secondary outcomes evaluated change in condoms, fentanyl test strips (FTS), and sharps containers dispensed. Data were collected from HRVM software and clinical logs. Pre/post totals were compared with Chi-square goodness-of-fit tests (α\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll supply categories increased significantly post-HRVM implementation (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Syringe distribution increased 9.5-fold (3,420 to 32,390; +847%), condoms 16.9-fold (854 to 14,475; +1,595%), sharps containers 9-fold (74 to 664; +797%), and FTS 3.6-fold (1,857 to 6,701; +261%). HRVMs accounted for 59\u0026ndash;101% of these increases.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eHRVM installation was associated with substantial, sustained growth in supply distribution, suggesting HRVMs can expand low-barrier access and complement clinic-based services for Veterans facing logistical or stigma-related barriers. Rigorous time-series or regression studies linking distribution to clinical outcomes are warranted. Collectively, these findings support system-wide VA scale-up of HRVMs as a low-barrier complement to clinic-based services.\u003c/p\u003e","manuscriptTitle":"Evaluating the Impact of Harm Reduction Vending Machines on Supply Distribution: A 23-Month Pre/Post Evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-09 12:24:55","doi":"10.21203/rs.3.rs-7787003/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b2c3a8b2-8d55-4a97-92df-cbde6c22d706","owner":[],"postedDate":"January 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T20:54:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-09 12:24:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7787003","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7787003","identity":"rs-7787003","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}